Lisa Heitmann, L.C.S.W. CLIENT REGISTRATION FORM CT Lic.#004217
Date:_______________ Referred by:_________________________________________________________________
Permission to contact referral source? (Please Initial) ________Yes ________ No
PERSONAL INFORMATION
Name:____________________________________________________ Date of Birth____________________________
Address:_____________________________________________ Town:__________________________ Zip__________
Phone: (_________)_________________________ Cell (Other) Phone: (__________)___________________________
Email:____________________________________________ Permission to contact you by email? _____Yes _____No
Employer_________________________________________________________________________
Name and address of person responsible for charges______________________________________________________
Emergency Contact ____________________________________________Relationship to Client___________________
Emergency Contact Tel._______________________________________ Permission to contact? ______Yes ______ No
HEALTH INSURANCE INFORMATION
Primary Insurance Company___________________________________________________________
Identification Number___________________________________________Group Number__________________________
Name of Insured (Subscriber)___________________________________________Birth Date_______________________
Address (If different from client) ______________________________________________________________________
Relationship to Client__________________________________________________________________
I have a secondary insurance company/policy: ______Yes _______ No
Authorization to Pay Insurance Benefits: I hereby direct my insurance carrier to make payments directly to the Provider for Health Insurance benefits otherwise payable to me. I understand I am financially responsible for charges not covered by this authorization(including insurance co-payments and deductibles that are due at time of service). This assignment of benefits shall be valid for the duration of my treatment.
Signature of Client/Guardian________________________________________________Date____________________
Authorization for Release of Information: I hereby authorize the Provider to release to his/her contracted billing services company and to my insurance company any billing and medical information necessary to process claims for services rendered to me by the Provider. This authorization is limited to the release of only that information necessary to substantiate and process health insurance claims. This authorization shall be valid for the duration of my treatment.
Signature of Client/Guardian________________________________________________Date____________________
Authorization for follow-up contact and informational mailings:
_____I hereby authorize the Provider to contact me via phone, email, or letter for follow-up after termination of services.
_____I hereby authorize the Provider to email me or send me informational literature regarding additional services available
such as workshops, treatment groups and seminars.
The above authorizations shall be valid throughout treatment and for a period of one year from my last session with the Provider.
Signature of Client/Guardian________________________________________________Date___________________
(For office use) Dx: _____________________
Rvs: 4/20/2013